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Insurance coverage of IVF may decrease multiple pregnancies

NEW YORK (Reuters Health) - After the Canadian province of Quebec began fully covering in vitro fertilization (IVF), more of the fertility treatments were performed and the rate of twin and triplet births fell, a new study found.

Babies are pictured in a maternity ward at the Munich hospital 'Rechts der Isar' January 18, 2011. REUTERS/Michaela Rehle

Quebec’s universal health insurance started covering all IVF-related costs in mid-2010. The new research is based on data from the first full year of coverage.

“Multiple pregnancies have important health consequences for pregnant women and their babies,” said lead author Dr. Maria Velez, from the University of Montreal.

Multiple pregnancies have an emotional and economic impact on families and cost the health system, which is a delicate point to bring up with patients dealing with fertility issues, she told Reuters Health by email. Patients are often misinformed about the negative consequences of multiple pregnancies, she said.

“Our obligation as medical doctors is to place the health of our patients above all,” Velez said. “Our role is to prevent a patient choosing a treatment that may cause harm if there is a safer alternative.”

Five fertility centers offer IVF in Quebec. The new study compared data from the Canadian Assisted Reproductive Technologies Register from those centers in 2009, before IVF was covered, and in 2011.

There were 1,875 fresh IVF cycles performed in 2009, which rose to 5,489 cycles in 2011. The number of clinical pregnancies and projected live births increased, while the rate of multiple pregnancies decreased from 29 percent to six percent.

And although public coverage of IVF led to more government spending per treatment cycle, the cost per live birth decreased, according to results published in Human Reproduction.

Researchers said the rate of multiple pregnancies likely fell because in Quebec, as in other areas with covered IVF, public policy requires that only one embryo be transferred at a time into women under age 36, called single-embryo transfer (SET). There were no restrictions on the number of embryos transferred at one time before the public coverage policy.

Under the policy, women who undergo IVF can still have several eggs harvested and embryos produced at once, but only one fresh one is implanted. The rest are frozen, and if the first embryo does not survive, another can be thawed and implanted.

Single-embryo transfer was much more common under universal coverage: 32 percent of cycles were elective SET in 2011, compared to two percent in 2009.

“This confirms what a lot of IVF practitioners have held in the U.S., that with insurance coverage single-embryo transfers are more likely to be done which is going to lower multiple birth rates which is safer and less expensive,” said Dr. Bradley J. Van Voorhis, director of the IVF Program at the University of Iowa Carver College of Medicine in Iowa City.

Van Voorhis was not part of the Quebec study.

“Covered couples are more willing to transfer only one knowing they can do another frozen one later at no extra cost,” he told Reuters Health.

Many European countries including France, Germany and Denmark cover some or all of IVF treatment costs.

In the U.S. and other areas where IVF is not covered, many families feel economic pressure to get the most out of each cycle and will have several embryos transferred at once, Van Voorhis said.

Under Quebec’s public program, one IVF cycle cost C$4,759, or about $4,374. In the U.S., one IVF cycle costs an average of $12,400, according to the American Society for Reproductive Medicine. Some states require insurance companies to cover at least some of that cost, but many states do not.

“In the U.S. I need to get pregnant now, in this cycle,” Van Voorhis said. “It’s disappointing and costs more money to do a frozen transfer later.”

The downside of SET is a lower fresh pregnancy rate, as happened in Quebec, but Van Voorhis believes if researchers had been able to track the total pregnancy rate including fresh and frozen embryos, it would have been equal or nearly equal to the pregnancy rate in 2009.

Providers in the U.S. already encourage their patients to choose SET, he said.

“Right now we’re in a position where physicians are trying very hard to use only single-embryo transfer more and more often,” he said. “If you look at national trends that’s happening.”

The U.S. probably doesn’t require a policy enforcing SET, but insurers might move to cover more fertility treatments if coverage leads to lower costs, as it did in Quebec, he said.

“I think it is a desirable trend that more infertility coverage be provided,” Van Voorhis said. “This is an encouraging finding that might influence payers to reconsider whether or not they will cover IVF, as they may ultimately benefit by the reduced cost.”

SOURCE: Human Reproduction, online April 4, 2014.